The Optimist

Democracy Inaction

Why representative government can't solve the world's other social problems.

As protesters from Benghazi to Sanaa risk their lives in the name of democratic freedoms, while Bush-era stalwarts cry victory for the "Freedom Agenda" and their opponents note that freedom in Egypt and Tunisia came from within, it is worth remembering two things: that the right to vote is worth such sacrifice, and that it is far from a guarantee of freedom.

Democratic institutions may be part of the secret to long-term growth (if not to the short-term kind). As Amartya Sen has pointed out, they don't tend to let their citizens starve to death. And people living in democracies report themselves marginally happier than people living under other forms of government. As we all know by now, democracies don't go to war with each other (much).

But for all of their positive attributes, democracies can be shallow and easy to overturn. First, a lot of democracies don't stay democracies. You don't have to go quite as far as Niall Ferguson -- who has argued that recent events in the Middle East could lead to a New Caliphate intent on Islamic global revolution -- to worry that newly democratic regimes might fall back toward more autocratic rule. Indeed, many people in Egypt were concerned over just this thing as the March 19th vote on the country's new constitution approached.

Democracies can also be shallow in their roots. Notre Dame's Christian Davenport and University of Wisconsin-Milwaukee's David Armstrong found that "limited" democracies -- countries with the vote but with less than free or fair elections -- were no better at protecting civil rights than non-democracies. Davenport even suggests that limited democracies include some of the worst abusers. David Richards at SUNY Binghamton University similarly suggests that there is no link between the mere presence of national elections and observance of human rights.

In 1997, Fareed Zakaria coined the term "illiberal democracies" to describe this phenomenon of democratic governments running amok with civil rights. But he wasn't describing a new type of regime -- throughout history, most democracies have, in fact, been markedly illiberal. The word itself, after all, comes from ancient Athens: a city that tolerated slavery, denied women participation in public life, and had a weak record on fair trial, empirically demonstrated by the firsthand experience of the philosopher Socrates. The protection of broader rights in putative democracies has been patchy ever since. The United States ratified a constitution dedicated to representative government in 1788, but only finally abolished slavery in 1865, guaranteed the vote to women in 1920, and only passed the Civil Rights Act ending racial segregation and discriminatory voter registration practices 176 years after the Constitution was ratified.

And the lion of liberty, Winston Churchill, believed his democratic bona fides were in no way compromised by a determination to deny votes to women or democracy to India and other parts of the British Empire. He was also happy to say of Native Americans that "I do not admit that a wrong has been done to these people by the fact that a stronger race, a higher-grade race, a more worldly wise race to put it that way, has come in and taken their place."

Moving on to the (old) Empire, India still faces human rights challenges despite being the world's largest democracy since 1947. The country has, it's true, made considerable progress over that time in social and economic development. Nevertheless, there is continuing discrimination against dalits -- "untouchables" -- which Prime Minister Manmohan Singh has likened to apartheid (not that he's had much success in solving the problem). And there are widespread accusations of torture by Indian security forces in Kashmir.

The gap between democracy and civil rights isn't a matter of government institutions falling behind the popular will. In fact, it often reflects popular attitudes across the world. The same polls that suggest ubiquitous global support for statements like "democracy may have its problems, but it's better than any other form of government" also report considerable variation in answers to questions about civil rights.

For example, Islamic and Western countries score almost exactly the same in popular opinion polls when it comes to attitudes toward democracy and democratic ideals, note Pippa Norris and Ronald Inglehart of Harvard University and the University of Michigan, respectively. But support for gender equality, divorce, and abortion is notably lower in Islamic countries, and acceptance of homosexuality hardly registers. (Indeed, homosexuality is still illegal in 80 countries, including many democratic ones, according to the U.N.'s Human Development Report.)

In Egypt, the harassment and intimidation of women holding a rally in Tahrir Square on International Women's Day highlights the fact that while democracy has finally arrived, some things take longer. Women in the Arab world occupy only 9.5 percent of parliamentary seats -- the lowest of any region in the world. Less than 35 percent of women are in the workforce in the Middle East and North Africa, compared with a global average of 56 percent. These statistics are unlikely to improve just because Hosni Mubarak has decamped to Sharm el-Sheikh. In 2009 Afghanistan -- another beneficiary of American enthusiasm for democratization -- saw its democratically elected parliament pass a law that denied Shiite women the right to leave their house without permission from a male relative and legalized rape within marriage.

To repeat: Democracy is a great thing in its own right. And over the long term it appears to be linked to a range of positive outcomes from wealth to health and even to happiness. That means it is wonderful news that the world is more democratic than ever before and, due to the bravery of protesters in Tunisia, Egypt, and hopefully elsewhere in the Middle East and beyond, about to get even more so. But democracy is no instant panacea -- especially not for wounded liberties. History, it seems, won't end when the last dictator falls.


The Optimist

The Civil War That Killed Cholera

Why the best ideas for fighting some diseases may come from poor countries, not rich ones.

This Saturday marks the 40th anniversary of Bangladesh's war for independence from Pakistan. Given how bloody the war proved to be, and how limited development progress in the country has been since then, it might seem like a dubious occasion for those of us far from Dhaka to celebrate. But the war does have one unambiguously positive legacy: It gave the world an approach to dealing with cholera and other diarrheal diseases that has since saved many more lives than were lost during the fighting.

Cholera outbreaks have been a regular feature of urban living worldwide for centuries. The disease spreads through contaminated water and produces a toxin in the small intestine that leads to muscle spasms, abdominal pains, vomiting, and -- deadliest of all -- gushing diarrhea. This highly infectious liquid is the usual culprit in cholera outbreaks --  it contaminates water supplies, thereby reaching new hosts.

After a series of outbreaks in mid-19th century London took tens of thousands of lives, doctors and civic leaders pinned the blame, accurately, on the city's appallingly inadequate sanitation system. Writers at the time described huge piles of human and animal excrement collecting in the streets and fetid rivers almost solid with waste. The solution, devised by civil engineer Joseph Bazalgette and completed in 1865, was a network of five new sewer lines that transported waste out of the city. With that momentous project, London freed itself from major cholera outbreaks.

The problem, however, was that such solutions were expensive and complicated. Lacking the genius of Bazalgette and the wealth of empire, most of the rest of the world went on suffering from diarrheal disease without much respite well into the 20th century. But while it is still the case today that only half of the developing world's population has access to well-built latrines or septic and sewage systems, the death toll from waterborne disease has been dropping dramatically around the globe. And the gains against cholera and its relatives are mostly due not the model of Victorian England, but to the type of approaches pioneered in war-torn, poverty-stricken Bangladesh.

As troops loyal to West Pakistan fought Bengali paramilitaries and Indian troops over the course of 1971, 9 million refugees flooded across the border of what was then East Pakistan into India. At the time, Dr. Dilip Mahalanabis was working in a refugee camp in Bangaon, in India's state of West Bengal, home to more than 350,000 refugees. He faced an epidemic of diarrheal disease spreading death throughout the camp, with mortality rates among infected patients running as high as 20 to 30 percent. At the time, intravenous salt solution was the standard response to diarrheal dehydration. But Mahalanabis had only two aides capable of administering intravenous drips, and supplies were running out. Overwhelmed, he turned to what hospital workers considered a decidedly inferior approach to tackling dehydration: giving people sugar-salt solution to swallow, or oral rehydration.

We usually rehydrate orally: it is called drinking. Unlike intravenous drips, downing a glass of solution doesn't take skilled assistance -- it also tastes great to people who are dehydrated (though less so to the rest of us -- imagine drinking sweetened sea water). Mahalanabis just set up drums of the solution and told family members to keep on coming back with cups and bottles to fill until their relatives refused to drink more of the stuff. Rather than treating a few lucky victims who managed to make it to the clinic, the doctor was reaching people all across the camp. Death rates dropped from 20 to 30 percent to a stunning 3 percent.

Since 1971, and with the active support of the World Health Organization and donors, this type of oral rehydration has become a standard treatment for diarrheal disease. Sugar-salt packages mixed in the right proportions are now widely available for a few cents a dose, and even cheaper tools of prevention are available. There are bottles designed to use sunlight to disinfect water; programs encouraging people to add a small amount of bleach to drinking water have reduced diarrhea cases by between 50 and 80 percent.

As cheap prevention and treatment techniques have spread around the globe, cholera deaths are increasingly rare worldwide. (An exceptional outbreak in Zimbabwe that took the lives of more than 4,000 people in 2008 and 2009 was a sign of how far Robert Mugabe's regime had driven public health provision into the ground in that country.) Related to this change, the impact of piped water and network sanitation access on health outcomes has declined, to the extent that one multicountry study of child mortality in the developing world suggested that universal access to improved water and sanitation would reduce global child mortality rates by as little as 3 percent. The potential impact of parents learning more about prevention and treatment -- and acting on the knowledge -- was more than 10 times as great.

There is still a long way to go in spreading knowledge, of course. According to the World Bank, in sub-Saharan Africa only one-third of children under 5 with diarrhea are treated with oral rehydration and continued feeding. As I noted in my most recent book, the percentage of parents in India who think the correct treatment for a child with diarrhea is to reduce the amount they are given to drink -- absolutely the wrong thing to do -- varies considerably from state to state. Less than 5 percent give this wrong answer in states like Kerala. More than 50 percent suggest this response in West Bengal, the original proving-ground of oral rehydration therapy -- where child mortality in the 1990s was about three times higher than it was in Kerala.

Nonetheless, progress in the technologies of public health and the spread of health knowledge have dramatically reduced cholera's toll. It used to take armies of engineers and considerable wealth to achieve what today's illiterate parent can achieve for cents. And that suggests something about policymaking.

In the perfect world, everyone would have 24-hour access to clean water and networked sanitation services. In the meantime, it's important to remember that each networked sewage connection costs magnitudes more than home-based prevention and other underutilized treatment options. Perhaps governments and aid agencies should take some of the money dedicated to recreating Bazalgette's subterranean cathedrals like the troubled Fallujah sewage project in Iraq and spend it instead on teaching people how to mix oral rehydration solutions or disinfect water. As we learned from Dr. Mahalanabis 40 years ago, a little sweetened seawater goes a long way.